Depression

Depression is a more disabling condition than angina, arthritis, asthma and diabetes World Health Organization research shows.

"A vast sea of misery could be avoided if this

condition received the same attention and

resources as Aids or cancer."

Marjorie Wallace, Sane

And those with depression plus a chronic illness, such as diabetes, fare particularly badly, the study of more than 245,000 people suggests.

Better treatment for depression would improve people's overall health, the researchers concluded in the Lancet.

Experts called for better funding for mental health services.

Dr Somnath Chatterji and colleagues asked people from 60 countries taking part in the World Health Survey a variety of questions about their health, such as how they sleep, how much pain they have, and whether they have any problems with memory or concentration.

Participants were also asked about how they manage with day-to-day tasks

After taking into account factors such as poverty and other health conditions, the researchers found that depression had the largest effect on worsening health.

And people with depression who also had one or more chronic diseases had the worst health scores of all the diseases looked at or combinations of diseases.

Urgency

Dr Somnath Chatterji said: "The co-morbid state of depression incrementally worsens health compared with depression alone, with any of the chronic diseases alone, and with any combination of chronic diseases without depression.

"These results indicate the urgency of addressing depression as a public health priority to reduce disease burden and disability, and to improve the overall health of populations."

The team called on doctors around the world to be more alert in the diagnosis and treatment of the condition, noting that it is fairly easy to recognise and treat.

Marcus Roberts, head of policy at mental health charity Mind, said the impact of depression could be devastating on relationships, finances and physical health.

"The treatment of depression must be given equal footing to the treatment of other conditions.

"While treatments for most physical health problems are readily accessible, mental health treatments such as talking therapies are limited, with some patients waiting months or even years for their first appointment with a therapist."

He added that mental health was often overlooked in those with chronic health problems, as doctors focused on the physical symptoms.

'Vast sea of misery'

A spokesperson for the Department of Health said: "Seven million adults in England suffer from a common mental health problem such as anxiety, eating disorders and depression.

"We recognise that many of those with depression do not receive treatment at the moment, partly because they do not seek appropriate help.

"The government is committed to providing greater choice and access to timely and appropriate treatment options and is currently working to expand access to and choice of talking therapies in the NHS."

Marjorie Wallace, chief executive of the mental health charity SANE, said: "We now have yet more evidence, as if it were needed, of the destructive and life-threatening effects of depression, which this global study shows can be an even greater danger than many chronic physical conditions.

"Yet even in developed countries like our own, proper diagnosis and appropriate treatment can be patchy at best.

"A vast sea of misery could be avoided if this condition received the same attention and resources as Aids or cancer."

Lynn Mitchell, who has terminal lung condition, chronic obstructive lung disease, reached rock bottom two years ago with her depression.

And although she had always received quick treatment for her lung problems on the NHS she struggled to get help for her mental illness.

Now she is on antidepressants and feels a different woman.

"I think if I hadn't had help with my mental attitude I would have been dead.

"My life was so bad and so bleak it was just horrendous really. I didn't want to live but now I don't want to die."

Anti-Depressants' 'Little Effect'

New generation anti-depressants have little clinical benefit for most patients, research suggests.

A University of Hull team concluded the drugs actively help only a small group of the most severely depressed. Marjorie Wallace, head of the mental health charity Sane, said that if these results were confirmed they could be "very disturbing".

But the makers of Prozac and Seroxat, two of the commonest anti-depressants, said they disagreed with the findings. A spokesman for GlaxoSmithKline, which makes Seroxat, said the study only looked at a "small subset of the total data available".

Reviewed Data

And Eli Lilly, which makes Prozac, said that "extensive scientific and medical experience has demonstrated it is an effective anti-depressant".

“There seems little reason to prescribe anti-depressant medication to any but the most severely depressed patients” Professor Irving Kirsch, University of Hull

Alan Johnson, the Health Secretary, has announced that 3,600 therapists are to be trained during the next three years in England to increase patient access to talking therapies, which ministers see as a better alternative to drugs. Patients are strongly advised not to stop taking their medication without first consulting a doctor.

The researchers accept many people believe the drugs do work for them, but argue that could be a placebo effect - people feel better simply because they are taking a medication which they think will help them.

In total, the Hull team, who published their findings in the journal PLoS Medicine, reviewed data on 47 clinical trials. They reviewed published clinical trial data, and unpublished data secured under Freedom of Information legislation.

They focused on drugs which work by increasing levels of the mood controlling chemical serotonin in the brain. These included fluoxetine (Prozac) and paroxetine (Seroxat), from the class known as Selective Serotonin Reuptake Inhibitors (SSRIs), alongside another similar drug called venlafaxine (Efexor) - all commonly prescribed in the UK.

The number of prescriptions for anti-depressants hit a record high of more than 31 million in England in 2006 - even though official guidance stresses they should not be a first line treatment for mild depression. There were 16.2m prescriptions for SSRIs alone.

The researchers found that the drugs did have a positive impact on people with mild depression - but the effect was no bigger than that achieved by giving patients a sugar-coated "dummy" pill.

People with severe symptoms appeared to gain more clear-cut benefit - but this might be more down to the fact that they were less likely to respond to the placebo pill, rather than to respond positively to the drugs.

Lead researcher Professor Irving Kirsch said: "The difference in improvement between patients taking placebos and patients taking anti-depressants is not very great. This means that depressed people can improve without chemical treatments. Given these results, there seems little reason to prescribe anti-depressant medication to any but the most severely depressed patients, unless alternative treatments have failed to provide a benefit." Professor Kirsch said the findings called into question the current system of reporting drug trials.

Reviewing Guidance

Dr Tim Kendall, deputy director of the Royal College of Psychiatrists Research Unit, has published research concluding that drug companies tend only to publish research which shows their products in a good light.

“These medicines have been licensed by a number of regulatory authorities around the world, who looking at all the evidence, have determined that they do work better than placebo ” Dr Richard Tiner, Association of the British Pharmaceutical Industry

He said the Hull findings undermined confidence in the ability to draw meaningful conclusions about the merit of drugs based on published data alone. He called for drug companies to be forced to publish all their data.

The National Institute for Health and Clinical Excellence (NICE) is currently reviewing its guidance on the use of antidepressants. Marjorie Wallace of Sane commented: "If these results were upheld in further studies, they would be very disturbing. The newer anti-depressants were the great hope for the future.... These findings could remove what has been seen as a vital choice for thousands in treating what can be a life-threatening condition."

Dr Andrew McCulloch, of the Mental Health Foundation, said: "We have become vastly over-reliant on antidepressants when there is a range of alternatives. Talking therapies, exercise referral and other treatments are effective for depression. It is a problem that needs a variety of approaches matched to the individual patient."

Dr Richard Tiner, of the Association of the British Pharmaceutical Industry, said there was no doubt that there was a "considerable placebo effect" from anti-depressants when treating people with mild to moderate symptoms. But he said no medicine would get a licence without demonstrating it was better than a placebo.

Dr Tiner said: "These medicines have been licensed by a number of regulatory authorities around the world, who looking at all the evidence, have determined that they do work better than placebo."

There's little question antidepressants are overprescribed and that many people who take the most popular drugs in America might do just as well with therapy or even a trip to the gym.

But that doesn't mean patients should toss out that bottle of Prozac or Paxil without careful consideration, warned psychology experts and scientists responding to a study that concluded placebos are as effective as medication in all but the most depressed.

And it certainly doesn't mean that severe depression — including the mood disorders that affect nearly 21 million adults in the U.S. — should be regarded as anything but the debilitating disease that it is.

"This is about very sick people; there's something wrong with their brains," said Dr. Helen Mayberg, a professor of psychiatry neurology at the Emory University School of Medicine. Mayberg and others worried that a study released Tuesday by Irving Kirsch of the University of Hull in England might lead depressed patients to abruptly stop their drugs without medical guidance. Kirsch and his researchers analyzed results of published and unpublished studies from the federal Food and Drug Administration to find that four of the most common new-generation antidepressants appear to help only the most severely depressed.

The drugs, which include those commonly known as Prozac, Effexor, Paxil and Serzone, worked no better than placebos in less severely depressed people, the researchers concluded. They suggested the drugs shouldn't be prescribed unless other therapies, including counseling and lifestyle changes such as exercise, have been tried.

Don't Stop Abruptly

About 118 million antidepressant prescriptions are issued in the U.S. each year, but starting or stopping the drugs should be done very carefully and under medical guidance.

"If you are currently taking an antidepressant drug and it's working for you, by no means stop," Mayberg said. Instead, patients should consider the new information and decide if it's time to evaluate their medication, added Deborah Serani, a psychologist in private practice in New York. Stopping the drugs abruptly can have dangerous results. "It can cause a backlash of severe depressive symptoms," said Serani, who herself has taken antidepressants for 15 years, including the generic version of Prozac.

The experts said the new study provided valuable insight, but that it was based on a limited number of short-term studies in a field in which long-term results are the point. Because no one knows what causes depression, and because treatment must be individualized, each case must be evaluated on its own merits, they added.

Serani has seen severely depressed patients fail to respond to antidepressants, and she's seen mild to moderately depressed patients respond very well. Other research has shown that patients respond better to a combination of medication and psychotherapy than to either treatment on its own, Mayberg said.

The power of the placebo effect on depression has long been recognized, said David Barlow, founder and director emeritus for the Center for Anxiety and Related Disorders at Boston University. Antidepressants likely are overprescribed, partly because of the hurried nature of care in the U.S. health system, Barlow noted. In busy primary care practices, there's considerable pressure to do something, anything, for patients suffering from mild to severe depression. "A placebo can make people feel better as well," he said.

Doctors must be more judicious in prescribing anti-depressants and patients must be more careful about requesting and using them, said Elinore McCance-Katz, a professor of psychiatry at the University of California at San Francisco. That can be complicated, especially in a country where antidepressants are advertised in magazines and on television. "What really bothers me is that big Pharma allows marketing directly to consumers," she said. Patients generally have little opportunity to verify the drug companies' claims, she added.

Depression Must Be Taken Seriously

The worst thing patients, their families and their doctors can do is decide that depression should not be treated seriously and carefully, Mayberg said. "Is this can we dump on the mentally ill once again?" she said. "Their families tell them to 'snap out of it' and to 'get a grip.'"

The entire field of neuro-psychiatry needs to work harder to find the cause of the depression and to discern effective ways to treat it so that people won't be tempted by simplistic solutions. "If that's all it took, working a little harder at the gym, we'd be done already," Mayberg said.

2 Mar 2008

In a BMJ clinical review on the presentation, assessment and management of depression in primary care, Finnish researchers report that despite increased awareness, rates of diagnosis remain suboptimal.

According to the World Health Organisation, depression is the greatest non-fatal, global burden of disease. Despite increasing understanding and awareness of the condition, diagnosis and treatment of depression in primary care is not always optimal. The review revealed that between 50% and 70% of patients with depression remain undetected by primary care. More specifically, they identified somatisation as one of the single-most important problems associated with a missed diagnosis.

“Given that about two thirds of depressed patients present mainly with somatic symptoms, detecting depression in connection with somatisation should be a core professional skill of doctors,” the authors stated.

They pointed out that patients at high risk of depression can be screened, primarily, using two simple questions: During the past month have you often been bothered by feeling down, depressed, or hopeless? During the past month have you often been bothered by having little interest or pleasure in doing things? Answering ‘yes’ to either question warrants further screening.

They also highlighted the significance of the patient–doctor relationship. A management plan needs to be created and negotiated together factoring in patient preferences, concomitant disorders and medications, the severity and type of symptoms, suicidal risk and availability of treatment options.

They noted that multifaceted interventions have been shown to be more effective than single component interventions, and stressed the importance of the collaborative care modelling. “The collaborative care model seems promising for enhancing treatment outcomes and bridging the gap between primary and secondary care, given that it allows patients to be managed by case managers or primary care providers under specialist supervision without the need for treatment elsewhere,” they claimed.

In the acute phase, the primary goal is the remission of symptoms, noting that remission of symptoms is associated with a better prognosis than the improvement of depressive symptoms without remission. Their review also outlined the types and appropriateness of psychological treatments, pharmacological treatments, and a combination of both.

An important aspect of management is evaluating treatment efficacy; the authors recommended careful monitoring irrespective of the treatment modality used as well as the use of structured measures of symptom severity and functional status.

The review stressed that where pharmacological therapy is the chosen treatment modality, should patients show insufficient response to therapy within 2–4 weeks, steps need to be taken to optimise the current treatment. This usually entails increasing the dose to the upper level of the standard dose. Should there be no improvement after 4 weeks of pharmacological treatment or less than moderate improvement within 4–8 weeks of psychological treatment, they recommended assessment of compliance to treatment and reassessment of the original diagnosis. Furthermore, owing to the strong tendency for depression to recur, they recommended that patients at high risk of recurrence be maintained on prophylactic treatment.

Research is ongoing and there are new generation antidepressants, such as melatonergic agomelatine, in development as well as computerised cognitive behaviour psychotherapy, the researchers concluded.

Data from the large Diabetes Prevention Program in the United States have suggested that antidepressant therapy increases the risk of type 2 diabetes two- to three-fold, but the risk is effectively eliminated in patients prescribed metformin.The data included 3,187 participants who were overweight and had impaired fasting glucose or impaired glucose tolerance and were therefore considered at high risk of diabetes. They were randomised to intensive lifestyle interventions, metformin, or placebo, and followed for an average of 3.2 years.At baseline about 10% had symptoms consistent with depression (usually mild) and 6% were taking antidepressants. The proportion with symptoms declined to 8% and the proportion taking antidepressants increased to 9% while the study was in progress.There was no association between depression symptoms at baseline and the subsequent likelihood of developing diabetes. However, use of antidepressants at baseline increased the risk of diabetes by a factor of 2.25 in the placebo arm and 3.48 in the lifestyle intervention arm. Continuous antidepressant use during the study was associated with higher diabetes risk in both these arms, as was intermittent use in the lifestyle arm. The risks were calculated after controlling for potential confounders including BMI, fasting glucose levels and physical activity.There were no links between antidepressants and diabetes onset in participants taking metformin.It was well known that people with diabetes had higher rates of depression than the general population, which in turn interfered with management of both disorders, but there had been very few studies on depression as a possible causative factor. Tricyclic antidepressants were known to cause weight gain and hyperglycaemia, but SSRIs (taken by about 80% of those being treated) were previously thought to be benign or even reduce weight and improve insulin sensitivity.The findings needed to be replicated and confirmed before the clinical implications could be defined. There were very large numbers of people at high risk of diabetes, and if 10% of them were also being treated with antidepressants then the public health consequences could be substantial.Reference Rubin, R. Ma, Y. et al. 2008, 'Elevated depression symptoms, antidepressant medicine use, and risk of developing diabetes during the Diabetes Prevention Program.' Diabetes Care vol. 31, pp. 420-426

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